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OBJECTIVE: This study examined the unique and interactive effects of PA volume and within-person fluctuations in PA volume (i.e., intraindividual variability in PA volume; PA-var) on preschoolers' (N = 141; 47.5% girls) ADHD symptoms. METHOD: Preschoolers wore accelerometers during the school day over a 2-week period. Teachers reported on children's hyperactive, impulsive, and inattentive symptoms on the ADHD Rating Scale-IV Preschool Version. RESULTS: In the context of regression models, higher levels of PA-var were linked with lower levels of impulsive symptoms. Higher levels of PA volume were linked with higher levels of hyperactive and inattentive symptoms, but only when PA fluctuation (i.e., PAvar) was relatively low. Post hoc analyses with teacher-reported impairment as the outcome revealed a significant interaction such that the positive association between PA volume and impairment was stronger at lower, as compared to higher, levels of PA-var. CONCLUSION: Larger fluctuations in preschoolers' PA volume may indicate lower risk for displaying impulsive symptoms. Moreover, preschoolers with high levels of PA that remain relatively consistent throughout the day may be at increased risk for exhibiting hyperactive and inattentive symptoms and related impairment, suggesting they are unable to regulate their activity to meet expectations in the school environment.
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Vírus , Humanos , Animais , Vírus/patogenicidade , Viroses/transmissão , Viroses/virologia , Internalização do VírusRESUMO
Background: Mucormycosis is a deadly invasive fungal infection recently included in the WHO priority pathogen list. Here we sought to describe epidemiological trends of mucormycosis in France, and to evaluate factors associated with mortality. Methods: From 2012 to 2022, we implemented a nationwide prospective surveillance programme for mucormycosis in France, focusing on epidemiology, species, seasonal variations. Factors associated with 3-month mortality were studied by univariable and multivariable logistic regression. Findings: Among 550 cases of mucormycosis, the main underlying conditions were haematological malignancy (HM, 65.1%, 358/550), trauma (8%, 44/550), diabetes (7.5%, 41/550) and solid-organ transplants (6.5%, 36/550). Site of infection was pulmonary in 52.4% (288/550), rhinocerebral in 14.5% (80/550), and cutaneo-articular in 17.1% (94/550). Main species identified were Rhizopus arrhizus (21%, 67/316), Rhizopus microsporus (13.6%, 43/316), Lichtheimia corymbifera and Mucor circinelloides (13.3%, 42/316 each), Rhizomucor pusillus (12%, 38/316), and Lichtheimia ramosa (10.8%, 34/316). We found associations between underlying condition, site of infection, and infecting species, including a previously undescribed triad of trauma, cutaneo-articular localisations, and L. ramosa/M. circinelloides. Diagnostic contribution of Polymerase Chain Reaction (PCR) increased from 16% (4/25) in 2012 to 91% (61/67) in 2022, with more than 50% of diagnoses relying solely on PCR in 2022. We also found seasonal variations with relatively more cases in autumn. Ninety-day mortality was 55.8% (276/495). Independent prognostic factors were age, diagnosis in Intensive Care Unit (ICU), and HM while diagnosis after 2015 (i.e. large implementation of PCR) and surgery were associated with reduced mortality. Interpretation: This study reveals major mucormycosis epidemiological changes in France, with a large predominance of HM patients, and a parallel between PCR multicentre implementation and improved prognosis. We also evidence new associations between species, localisations and risk factors, as well as seasonal variations. Funding: Recurrent financial support from Santé Publique France and Institut Pasteur.
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BACKGROUND: The Birth Satisfaction Scale-Revised (BSS-R) is a widely used, psychometrically robust and brief self-report measure of birth experience from the mothers perspective. The current study sought to adapt and validate the BSS-R for partners, evaluating key psychometric properties, including the underlying tri-dimensional factor structure of stress experienced, personal attributes and quality of care. AIM: To translate and validate a Czech speaking partner version of the Birth Satisfaction Scale-Revised (BSS-R) and examine key measurement characteristics and association with fundamental clinical outcome variables. METHOD: Following translation of the UK partner BSS-R into Czech, the Czech Partner BSS-R (CZP-BSS-R) was administered to 225 partners of women who had given birth within the past 5-years. Key psychometric characteristics were examined, including factor structure, divergent and known-groups discriminant validity and internal reliability. RESULTS: Established measurement models of the BSS-R observed in mothers were found to offer an excellent fit to partner data. The CZP-BSS-R also demonstrated excellent validity and reliability characteristics. CONCLUSIONS: The CZP-BSS-R was found to be valid and reliable, with results from Czech partners 'mirroring' factor structure and key validity characteristics previously established in Czech mothers. The BSS-R validated for completion by Czech speaking mothers now has a matched version available for use with Czech speaking partners.
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Standard models of well-child care may not sufficiently address preventive health needs of immigrant families. To augment standard individual well-child care, we developed a virtual group-based psychoeducational intervention, designed to be delivered in Spanish as a single, stand-alone session to female caregivers of 0-6 month-olds. The intervention included a video testimonial of an individual who experienced perinatal depression followed by a facilitated discussion by the clinic social worker and an orientation to relevant community resources by a community health worker. To assess feasibility and acceptability of the intervention, we conducted an open pilot within an academic pediatric practice serving predominantly Latinx children in immigrant families. Participants included 19 female caregivers of infants attending the practice, of whom 16 completed post-intervention measures and 13 completed post-intervention semi-structured interviews. Quantitative measures of acceptability and satisfaction with the intervention were high. We found preliminary effects of the intervention on postpartum depression knowledge and stigma in the expected direction. In interviews, participants described increases in their familiarity with postpartum depression and about relevant community resources, including primary care for caregivers. Participants reported an appreciation for the opportunity to learn from other caregivers and provided suggestions for additional topics of interest. Trial registration: Registered 6/21/22 as NCT05423093.
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Depressão Pós-Parto , Emigrantes e Imigrantes , Estudos de Viabilidade , Hispânico ou Latino , Mães , Atenção Primária à Saúde , Humanos , Hispânico ou Latino/psicologia , Feminino , Mães/psicologia , Atenção Primária à Saúde/organização & administração , Lactente , Adulto , Depressão Pós-Parto/etnologia , Depressão Pós-Parto/terapia , Recém-Nascido , Projetos Piloto , Conhecimentos, Atitudes e Prática em Saúde/etnologiaAssuntos
Objetivos , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
ABSTRACT: Fourel, L, Touzard, P, Fadier, M, Arles, L, Deghaies, K, Ozan, S, and Martin, C. Relationships between force-time curve variables and tennis serve performance in competitive tennis players. J Strength Cond Res 38(9): 1667-1674, 2024-Practitioners consider the role of the legs in the game of tennis as fundamental to achieve high performance. But, the exact link between leg actions and high-speed and accurate serves still lacks understanding. Here, we investigate the correlation between force-time curve variables during serve leg drive and serve performance indicators. Thirty-six competitive players performed fast serves, on 2 force plates, to measure ground reaction forces (GRF). Correlation coefficients describe the relationships between maximal racket head velocity, impact height, and force-time curve variables. Among all the variables tested, the elapsed time between the instants of maximal vertical and maximal anteroposterior GRF ( r = -0.519, p < 0.001) and the elapsed time between the instant of maximal anteroposterior GRF and ball impact ( r = -0.522, p < 0.001) are the best predictors of maximal racket velocity. Maximal racket head velocity did not significantly correlate with the mean or maximal vertical GRF or with the mean or maximum rate of vertical force development. The best predictor for impact height is the relative net vertical impulse during the concentric phase ( r = 0.772, p < 0.001). This work contributes to a better understanding of the mechanical demands of tennis serve motion and gives guidelines to improve players preparation and performance. Trainers should encourage their players to better synchronize their upward and forward pushing action during the serve to increase maximal racket head velocity. Players should also aim to improve their relative net vertical impulse to increase impact height through strength training and technical instructions.
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Desempenho Atlético , Tênis , Humanos , Tênis/fisiologia , Desempenho Atlético/fisiologia , Masculino , Adulto Jovem , Fenômenos Biomecânicos , Adulto , Comportamento Competitivo/fisiologia , Adolescente , Perna (Membro)/fisiologia , FemininoRESUMO
BACKGROUND: Evidence relating maternal birth experience to a range of maternal and neonatal outcomes is increasingly compelling. Consequently valid and reliable self-report of birth experience from the mothers perspective is critical. AIM: The current study sought to translate and validate a Hungarian-language version of the Birth Satisfaction Scale-Revised (BSS-R). METHOD: Following forward and backwards translation into Hungarian, the Hungarian BSS-R (HU-BSS-R) was administered to women in a major Transylvanian hospital maternity unit within 72 h postpartum. Key psychometric characteristics were then examined in relation to factor structure, divergent and convergent validity, internal consistency, and known-groups discriminant validity. RESULTS: Two-hundred and thirty-two women completed the HU-BSS-R. Confirmatory factor analysis revealed the HU-BSS-R to offer an excellent fit to data for the established tri-dimensional measurement model. The HU-BSS-R was also found to offer excellent convergent and divergent validity and known-groups discriminant validity. No significant differences were observed between internal consistency observations between the current study and the original UK validation study. CONCLUSIONS: The HU-BSS-R is a valid and reliable translation of the original BSS-R, it has proved itself to have excellent psychometric properties and is suitable for use in the Hungarian maternity context.
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Psicometria , Tradução , Humanos , Feminino , Hungria , Adulto , Psicometria/instrumentação , Psicometria/métodos , Psicometria/normas , Inquéritos e Questionários , Reprodutibilidade dos Testes , Gravidez , Satisfação do Paciente , Parto/psicologia , Traduções , Mães/psicologia , Mães/estatística & dados numéricosRESUMO
BACKGROUND: The 10-item Birth Satisfaction Scale-Revised (BSS-R) is a quick and easy survey instrument recommended by the International Consortium for Health Outcome Measures as the tool of choice for measuring women's birth satisfaction. AIM: To translate and validate a Vietnamese-language version of the BSS-R. METHOD: A quantitative cross-sectional method was used to gather data post translation and back-translation of a Vietnamese version of the BSS-R (VN-BSS-R). Data collected were psychometrically evaluated using key indices of validity and reliability. PARTICIPANTS: Vietnamese women who were within one month postpartum of birth (N = 383) took part in the study. RESULTS: Findings illustrate that a two-factor model offered excellent psychometric properties. With the two-factor VN-BSS-R, five items loaded onto a subscale 'Positive birth experiences' and the other five onto a second subscale 'Negative birth experiences'. This two-factor model offered a fit to data (root mean square error of approximation [RMSEA] = 0.07, 90% confidence interval [CI] [0.05, 0.09], root square mean residual [RMSE] = 0.04 and comparative fit index [CFI] = 0.97). Mean scores for the exploratory factor analysis [EFA]-derived 'positive' and 'negative' sub-scales were 17.12 (SD 2.34) and 8.40 (SD 4.18) respectively. CONCLUSION: The translated and validated VN-BSS-R is a psychometrically robust tool for measuring birth satisfaction in Vietnamese postpartum women.The VN-BSS-R is available for use to measure experiences and perceptions of intrapartum care received by Vietnamese women.
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BACKGROUND: The Vietnam midwifery report acknowledges that while health services are available in Vietnam, there is growing need to increase levels of respectful maternal care provided to women in labour. OBJECTIVE: In conjunction with newborns Vietnam charity, our objective was to assess the perceived continuous professional development needs of midwives working in Vietnam to inform development of an intranatal respectful maternal care education resource. METHOD: A qualitative exploratory descriptive method was used to conduct a training needs analysis, which identified perceived education requirements of midwives in Vietnam in relation to providing respectful maternal care. PARTICIPANTS: A convenience sample of midwives (n = 49) participated in the study. DATA-COLLECTION: Eight on-line focus groups were carried out in four hospitals (maternity units) across Vietnam using WebEx, with the interview schedule informed by the World Health Organization guide for delivering intrapartum care for a positive birth experience. DATA-ANALYSIS: Data were transcribed into English and analysed using the 6-steps of thematic analysis outlined by Braun and Clark. FINDINGS: Three themes and 9 sub-themes were developed from the data. The first theme addressed aspects that contribute towards creating a positive birth experience; the second theme observed barriers to changing practice; and the third theme noted that there are a variety of preferred teaching methods. CONCLUSIONS: In response to the training needs analysis, a respectful maternal care education resource has been designed to transform selected areas of intranatal care in Vietnam. Integrating the respectful maternal care educational resource into midwives' continuous professional development in Vietnam is intended to increase women's rights to have safe childbirth, which accommodates choice and control, and promotes a positive birth experience. RECOMMENDATIONS FOR PRACTICE: Post-completion and evaluation, we hope that the intranatal respectful maternal care educational resource will be rolled out to all practising midwives in Vietnam.
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Serviços de Saúde Materna , Tocologia , Recém-Nascido , Humanos , Feminino , Gravidez , Tocologia/educação , Pesquisa Qualitativa , Grupos Focais , VietnãRESUMO
BACKGROUND: Up to 2% of all pregnancies result in pregnancy loss between 14 + 0 and 23 + 6 weeks' gestation, which is defined as 'late miscarriage'. Lack of consensus about definition of viability paired with existing multiple definitions of perinatal loss make it difficult to define the term 'late miscarriage'. Parents who experience late miscarriage often have had reassuring scan-milestones, which established their confidence in healthy pregnancy progression and identity formation, which socially integrates their baby into their family. The clinical lexicon alongside the lack of support offered to parents experiencing late miscarriage may disclaim their needs, which has potential to cause adverse psychological responses. AIM: To review what primary research reports about parents' experiences and their perceived holistic needs following late miscarriage. METHODS: A narrative systematic review was carried out. Papers were screened based on gestational age at time of loss (i.e. between 14 + 0 and 23 + 6 weeks' gestation). The focus was set on experience and holistic needs arising from the loss rather than its clinical care and pathophysiology. Studies were selected using PRISMA-S checklist, and quality assessed using the Critical Appraisal Skills Program (CASP) tool. Thematic analysis was used to guide the narrative synthesis of findings. RESULTS: Six studies met the inclusion criteria. Three main themes emerged: communication and information-giving; feelings post-event; and impact of support provision. CONCLUSION: Literature about the experience of late miscarriage is scarce, with what was found reporting a lack of compassionate and individually tailored psychological follow-up care for parents following late miscarriage. Hence, more research in this arena is required to inform and develop this area of maternity care provision.
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AIM: This study aimed to develop a Japanese version of the Birth Satisfaction Scale-Revised and evaluate its reliability and validity. METHODS: After translating the Birth Satisfaction Scale-Revised into Japanese, we conducted an Internet-based cross-sectional study with 445 Japanese-speaking women within 2 months of childbirth. Of these, 98 participated in the retest 1 month later. Data were analyzed using the COSMIN study design checklist for patient-reported outcome measurement instruments. Content validity was evaluated through cognitive debriefing during the translation process into Japanese. Confirmatory factor analysis was conducted to verify structural and cross-cultural validities. For hypothesis testing, we tested correlations with existing measures for convergent and divergent validities, and for known-group discriminant validity, we made comparisons between types of childbirth. Internal consistency was calculated using Cronbach's α, and test-retest reliability was evaluated using the intraclass correlation coefficient. RESULTS: For the Japanese-Birth Satisfaction Scale-Revised, the established three-factor model fit poorly, whereas the four-factor model fit better. Full metric invariance was observed in both the nulliparous and multiparous groups. Good convergent, divergent, and known-group discriminant validities and test-retest reliability were established. Internal consistency observations were suboptimal; however for vaginal childbirth, the Cronbach's α of the total score was .71. CONCLUSIONS: The Japanese-Birth Satisfaction Scale-Revised is a valid and reliable scale, with the exception of internal consistency that requires further investigation. If limited to vaginal childbirth, research, clinical applications, and international comparisons can be drawn.
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Satisfação Pessoal , Humanos , Feminino , Estudos Transversais , Reprodutibilidade dos Testes , Japão , Psicometria , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Estimates of the stability of a preschooler's diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) into early elementary school vary greatly. Identified factors associated with diagnostic instability provide little guidance about the likelihood a particular child will have ADHD in elementary school. This study examined an approach to predicting age 6 ADHD-any subtype (ADHD-any) from preschoolers' demographics and ADHD symptoms. METHOD: Participants were 796 preschool children (Mage = 4.44; 51% boys; 54% White, non-Hispanic) recruited from primary pediatric care and school settings. Parents completed ADHD Rating Scales at child ages 4 and 5 years, and a structured diagnostic interview (DISC-YC) at ages 4 and 6. Classification tree analyses (CTAs) examined the predictive utility of demographic and symptom variables at ages 4 and 5 years for age 6 ADHD. RESULTS: Over half (52.05%) of preschoolers meeting diagnostic criteria for ADHD-any at age 4 did not meet those criteria at age 6; more than half (52.05%) meeting criteria for ADHD-any at age 6 had not met those criteria at age 4. A CTA conducted at age 4 predicted age 6 ADHD-any diagnosis 65.82% better than chance; an age 5 CTA predicted age 6 ADHD-any 70.60% better than chance. At age 4, likelihood of age 6 ADHD-any diagnosis varied from <5% to >40% across CTA tree branches and from <5% to >78% at age 5. CONCLUSIONS: Parent-reported patterns of preschool-age symptoms may differentially predict ADHD-any at age 6. Psychoeducation regarding these patterns may aid in decision about pursuing multidisciplinary evaluations or initiating treatment.
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Transtorno do Deficit de Atenção com Hiperatividade , Pré-Escolar , Masculino , Criança , Humanos , Feminino , Transtorno do Deficit de Atenção com Hiperatividade/terapia , Saúde Mental , Pais , Escolaridade , Instituições AcadêmicasRESUMO
BACKGROUND: Satisfaction with the birth experience has been established to be critical for the wellbeing of the mother. The Birth Satisfaction Scale-Revised (BSS-R) is a brief and psychometrically robust multi-dimensional self-report tool designed to assess birth experience. The current investigation sought to translate and validate a Czech Republic version of the BSS-R (CZ-BSS-R). METHODS: Following translation psychometric assessment of the CZ-BSS-R was undertaken using a cross-sectional design. A between-subjects design was incorporated in order to evaluate known-groups validity evaluation of the translated measure. Four hundred and sixty-five Czech-speaking women within the Czech Republic took part in the study. Confirmatory factor analysis was undertaken and divergent and convergent validity and internal consistency characteristics also evaluated. RESULTS: The CZ-BSS-R was observed to have excellent psychometric properties and conceptually and measurement faithful to the original English-language measure. Consistent with previous investigations using the BSS-R significant differences were found in scores as a function of delivery type. CONCLUSIONS: The CZ-BSS-R is a valid, robust and reliable measure of birth experience and suitable for use with Czech-speaking women in the Czech Republic. The study highlighted that instrument and emergency Caesarean section were associated with a lower level of birth satisfaction compared to vaginal delivery.
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Cesárea , Parto , Gravidez , Feminino , Humanos , República Tcheca , Estudos Transversais , Inquéritos e Questionários , Satisfação do Paciente , Reprodutibilidade dos Testes , Satisfação PessoalRESUMO
Interferometric scattering microscopy can image the dynamics of nanometer-scale systems. The typical approach to analyzing interferometric images involves intensive processing, which discards data and limits the precision of measurements. We demonstrate an alternative approach: modeling the interferometric point spread function and fitting this model to data within a Bayesian framework. This approach yields best-fit parameters, including the particle's three-dimensional position and polarizability, as well as uncertainties and correlations between these parameters. Building on recent work, we develop a model that is parameterized for rapid fitting. The model is designed to work with Hamiltonian Monte Carlo techniques that leverage automatic differentiation. We validate this approach by fitting the model to interferometric images of colloidal nanoparticles. We apply the method to track a diffusing particle in three dimensions, to directly infer the diffusion coefficient of a nanoparticle without calculating a mean-square displacement, and to quantify the ejection of DNA from an individual lambda phage virus, demonstrating that the approach can be used to infer both static and dynamic properties of nanoscale systems.
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Nutrient profiling (NP) models are useful for characterizing the healthfulness of foods and for underpinning various nutrition-related public health strategies. Recently, there has been a rapid increase in the number of NP models developed by different organizations worldwide. A systematic review (SR) summarizing the key characteristics of NP models with applications in government-led nutrition policies was carried out in 2016 and published by Labonté et al. [4]. Given the continuous proliferation of NP models, the current study aimed to update this SR. Systematic searches were performed in databases of both the peer-reviewed (n = 7) and grey (n = 1) literature to identify publications related to NP published between May 2016 and September 2020. The full text of relevant publications was assessed independently by 2 reviewers to build a list of potential models. Each model was classified as "already identified in the original SR" or as "newly identified." The eligibility of the "newly identified" models, and of some models excluded from the previous SR because their details were not known at that time, were then assessed independently by 2 reviewers based on pre-established criteria. A total of 151 potential NP models were assessed for eligibility, of which 93 were "newly identified," 28 were originally excluded from the previous SR, and 30 were identified from additional online searches during the eligibility assessment stage. Twenty-six models met the inclusion criteria. Their most frequent applications were food labeling (n = 17) and regulation of food marketing to children (n = 7). They all included nutrients to limit, with sodium, saturated fat, and total sugars being the most frequently considered. Content or face validity testing was conducted for 11 (42%) of the included models. As NP models are increasingly used worldwide to support public health strategies, having an up-to-date resource listing them and detailing their characteristics is crucial. PROSPERO #CRD42021259041.
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Doenças não Transmissíveis , Criança , Humanos , Valor Nutritivo , Doenças não Transmissíveis/prevenção & controle , Alimentos , Nutrientes , Política NutricionalRESUMO
Patient experiences and perspectives on trial participation and follow-up may influence their compliance with research procedures or negatively impact their well-being. We aimed to explore the acceptability and feasibility of home-based and hospital-based follow-up modalities among COVID-19 patients enrolled in the ANTICOV ANRS COV33 Coverage-Africa trial in Burkina Faso and Guinea. The trial (2021-2022) evaluated the efficacy of treatments to prevent clinical worsening among COVID-19 patients with mild to moderate symptoms. Patients were either based at home or hospitalized, as per national recommendations, and followed-up through face-to-face visits and phone calls. We conducted a mixed-methods sub-study administering a questionnaire to all consenting participants and individually interviewing purposively selected participants. We performed descriptive analyses of Likert scale questions for the questionnaires and thematic analysis for the interviews. We conducted framework analysis and interpretation. Of the 400 trial patients, 220 completed the questionnaire (n = 182 in Burkina Faso, n = 38 in Guinea) and 24 were interviewed (n = 16 and n = 8, respectively). Participants were mostly followed-up at home in Burkina Faso; all patients from Guinea were first hospitalized, then followed-up at home. Over 90% of participants were satisfied with follow-up. Home follow-up was considered acceptable if (i) participants perceived they were not severely ill, (ii) it was combined with telemedicine, and (iii) the risk of stigma could be avoided. Hospital-based follow-up was viewed as a way to prevent contamination of family members, but could be badly experienced when mandatory and conflicting with family responsibilities and commitments. Phone calls were seen as reassuring and as a way to ensure continuity of care. These overall positive findings support the development of home-based follow-up for mildly ill patients in West-Africa, provided that both emotional and cognitive factors at individual, familial/inter-relational, healthcare and national levels be addressed when planning the implementation of a trial, or developing any public health strategy.
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INTRODUCTION: Evaluation in healthcare services has become a priority, globally1. The Government of Ireland has highlighted the importance of stakeholder engagement to identify the needs of women in the design and delivery of high-quality health services, driven by necessity rather than financial ability2. The Birth Satisfaction Scale-Revised (BSS-R), an internationally validated tool, and recommended for measuring childbirth satisfaction by the International Consortium for Health Outcomes Measurement (ICHOM)3; however, it has yet to be considered in the Irish context. The aim of the study was to explore birth satisfaction with a sample of new mothers in Ireland. METHODS: A mixed-methods study was conducted including a survey that involved collection of data from the BSS-R 10-item questionnaire from 307 mothers over an 8-week period in 2019, in one urban maternity hospital in Ireland. Quantitative and qualitative data were collected. Qualitative data from the free-text comments of the survey questions were analyzed using content analysis. RESULTS: Overall, women reported positive relationships with their care providers and were satisfied with the communication and support they received, as well as high levels of control and choice. Postnatal care, however, was highlighted as being less satisfactory with staffing levels described as inadequate. CONCLUSIONS: Understanding women's birth experiences and what is important to them could facilitate midwives and other health professionals to improve the quality of their care and develop guidelines and policies that focus on women and their families' needs. The vast majority of women rated their birthing experience as extremely positive. The main elements of care that contributed to a positive birthing experience for women were quality relationships with clinicians, choice and control, and emotional safety.